Co-Operative Pain Education and Self-management (COPES) Expanding Treatment for Real-World Access (ExTRA): Pragmatic Trial Protocol

Intervention delivery complexity and adaptations for implementation of non-pharmacologic pain interventions

Background

Delivering evidence-based interventions remains challenging, particularly for complex conditions like chronic musculoskeletal pain. Non-pharmacologic treatments are recommended for many pain conditions, but implementing these can be difficult due to their complexity and resource demands. Pragmatic trials, especially embedded designs, provide a method to see how interventions are being implemented and adapted in real-world settings throughout the trial process. This study explored how intervention delivery complexity and adaptations differ between non-pharmacologic pain trials and non-pain trials to provide guidance on future treatment delivery and implementation.

Methods

From July to October 2023, an online survey was distributed to members of three NIH Trial Collaboratories to assess intervention delivery complexity and adaptations during their pragmatic trials. Participants rated their trial's intervention delivery complexity using a 7-item tool and reported any adaptations to intervention delivery throughout the trial process. Data analysis compared complexity and adaptations between the two trial types to explore differences and relationships between intervention delivery complexity and adaptations.

Results

We analyzed 12 pain and 12 non-pain trials and found that intervention delivery complexity was not discernibly different between the two trial types, however, pain trials did have a slightly higher average intervention delivery complexity, overall. Pain trials also had more adaptations in the workflow domain compared to non-pain trials, while adaptations across other domains were similar between the two types. Workflow emerged as the most challenging domain for adaptation among all trials.

Conclusion

Intervention delivery complexity may be higher for pragmatic trials that are investigating non-pharmacologic pain interventions versus non-pain trials, but only in very specific areas.

The Interactive Care Coordination and Navigation mHealth Intervention for People Experiencing Homelessness: Cost Analysis, Exploratory Financial Cost-Benefit Analysis, and Budget Impact Analysis

Background

The Interactive Care Coordination and Navigation (iCAN) mobile health intervention aims to improve care coordination and reduce hospital and emergency department visits among people experiencing homelessness.

Objective

This study aimed to conduct a three-part economic evaluation of iCAN, including a (1) cost analysis, (2) exploratory financial cost-benefit analysis, and (3) budget impact analysis (BIA).

Methods

We collected cost and expenditure data from a randomized controlled trial of iCAN to conduct a cost analysis and exploratory financial cost-benefit analysis. Costs were classified as startup and recurring costs for participants and the program. Startup costs included participant supplies for each participant and SMS implementation costs. Recurring costs included the cost of recurring services, SMS text messaging platform maintenance, health information access fees, and personnel salaries. Using the per participant per year (PPPY) costs of iCAN, the minimum savings reduction in the average health care costs among people experiencing homelessness that would lead to a benefit-cost ratio >1 for iCAN was calculated. This savings threshold was calculated by dividing the PPPY cost of iCAN by the average health care costs among people experiencing homelessness multiplied by 100%. The benefit-cost ratio of iCAN was calculated under different savings thresholds from 0% (no savings) to 50%. Costs were calculated PPPY under different scenarios, and the results were used as inputs in a BIA. A probabilistic sensitivity analysis was conducted to incorporate uncertainty around cost estimates. Costs are in 2022 US $.

Results

The total cost of iCAN was US $2865 PPPY, which was made up of US $265 in startup (9%) and US $2600 (91%) in recurring costs PPPY. The minimum savings threshold that would cause iCAN to have a positive return on investment is 7.8%. This means that if average health care costs (US $36,917) among people experiencing homelessness were reduced by more than 7.8% through iCAN, the financial benefits would outweigh the costs of the intervention. When health care costs are reduced by 25% ($9229/$36,917; equal to 56% [$9229/$16,609] of the average cost of an inpatient visit), the benefit-cost ratio is 3.22, which means that iCAN produces US $2.22 in health care savings per US $1 spent. The BIA estimated that implementing iCAN for 10,250 people experiencing homelessness over 5 years would have a financial cost of US $28.7 million, which could be reduced to US $2.2 million if at least 8% ($2880/$36,917) of average health care costs among people experiencing homelessness are reduced through the intervention.

Conclusions

If average costs of emergency department and hospital visits among people experiencing homelessness were reduced by more than 7.8% ($2880/$36,917) through iCAN, the financial benefits would outweigh the costs of the intervention. As the savings threshold increases, it results in a higher benefit-cost ratio.

Implementation, intervention, and downstream costs for implementation of a multidisciplinary complex pain clinic in the Veterans Health Administration

OBJECTIVE

To determine the budget impact of implementing multidisciplinary complex pain clinics (MCPCs) for Veterans Health Administration (VA) patients living with complex chronic pain and substance use disorder comorbidities who are on risky opioid regimens.

DATA SOURCES AND STUDY SETTING

We measured implementation costs for three MCPCs over 2 years using micro-costing methods. Intervention and downstream costs were obtained from the VA Managerial Cost Accounting System from 2 years prior to 2 years after opening of MCPCs.

STUDY DESIGN

Staff at the three VA sites implementing MCPCs were supported by Implementation Facilitation. The intervention cohort was patients at MCPC sites who received treatment based on their history of chronic pain and risky opioid use. Intervention costs and downstream costs were estimated with a quasi-experimental study design using a propensity score-weighted difference-in-difference approach. The healthcare utilization costs of treated patients were compared with a control group having clinically similar characteristics and undergoing the standard route of care at neighboring VA medical centers. Cancer and hospice patients were excluded.

DATA COLLECTION/EXTRACTION METHODS

Activity-based costing data acquired from MCPC sites were used to estimate implementation costs. Intervention and downstream costs were extracted from VA administrative data.

PRINCIPAL FINDINGS

Average Implementation Facilitation costs ranged from $380 to $640 per month for each site. Upon opening of three MCPCs, average intervention costs per patient were significantly higher than the control group at two intervention sites. Downstream costs were significantly higher at only one of three intervention sites. Site-level differences were due to variation in inpatient costs, with some confounding likely due to the COVID-19 pandemic. This evidence suggests that necessary start-up investments are required to initiate MCPCs, with allocations of funds needed for implementation, intervention, and downstream costs.

CONCLUSIONS

Incorporating implementation, intervention, and downstream costs in this evaluation provides a thorough budget impact analysis, which decision-makers may use when considering whether to expand effective programming.

Optimizing Diversity, Equity and Inclusion in Pragmatic Clinical Trials: Findings from the Pain Management Collaboratory

The National Institutes of Health, U.S. Department of Defense, and U.S. Department of Veterans Affairs established a Pain Management Collaboratory (PMC) in 2017, with the purpose of implementing and evaluating nonpharmacological approaches for management of pain and co-occurring conditions in military and veteran healthcare systems through the execution of pragmatic clinical trials. The purpose of the current study is to detail and critically examine recruitment and retention procedures across the PMC's large-scale multi-site pragmatic clinical trials, with attention to efforts made by trialists to diversify their study samples. Team members from 11 pragmatic clinical trials completed semi-structured interviews that focused on the meaning of diversity to the trial teams when planning the composition of their samples, methods used to recruit and retain diverse samples of patients, and planned analyses that take into consideration diverse subgroups of patients. Nearly 18,000 patients have been enrolled across trials, 22% of whom were assigned female sex at birth and 34% of whom identify with a marginalized race or ethnicity. Respondents highlighted study site selection, formation of partnerships with patient groups, and leveraging of data informatics as strategies that aided in the recruitment of patients diverse in terms of birth sex, race, and ethnicity. Notably, trialists adopted a narrow definition of diversity that did not take into consideration multiple intersecting identities of trial participants. Based on experiences of the PMC, we provide 14 recommendations on ways to diversify patient samples in clinical pain research. PERSPECTIVE: This article describes challenges posed, and opportunities provided, with pain pragmatic clinical trial designs, emphasizing approaches that optimize the inclusion of social identity groups that have historically been under-represented in pain research.

Do mindfulness interventions cause harm? Findings from the Learning to Apply Mindfulness to Pain (LAMP) Pragmatic Clinical Trial

BACKGROUND

Although mindfulness-based interventions (MBIs) are widely used in clinical and nonclinical settings, there has been little systematic study of their potential risks. To address this gap, we examined differences in psychological and physical worsening among participants in the usual care and intervention conditions of a 3-group, randomized pragmatic trial (Learning to Apply Mindfulness to Pain [LAMP]) that tested the effectiveness of 2 approaches to delivering MBIs to patients with chronic pain.

METHODS

The sample consisted of 374 male and 334 female patients with chronic pain enrolled in the LAMP trial who completed a 10-week follow-up survey, 61% of whom had a mental health diagnosis. Psychological and physical worsening was assessed by a checklist asking whether participants experienced specific symptoms since beginning the study. We used multivariable logistic regression models with imputed data to determine whether predicted probabilities of increased symptoms differed between usual care and the 2 MBIs.

RESULTS

Participants in usual care were more likely to report experiencing increased psychological and physical worsening than were those in the MBIs, including an increase in disturbing memories; sadness, anxiousness, and fatigue; isolation and loneliness; and feeling more upset than usual when something reminded them of the past.

CONCLUSIONS

MBIs do not appear to cause harm, in terms of increased symptoms, for this population of patients with chronic pain and high levels of mental health comorbidities.

CLINICAL TRIAL REGISTRATION

Preregistration with an analysis plan at www.ClinicalTrials.gov: NCT04526158. Patient enrollment began December 4, 2020.

Recommendations for monitoring adherence and fidelity in pragmatic trials based on experience in the Pain Management Collaboratory

OBJECTIVE

Most pragmatic trials follow the PRagmatic Explanatory Continuum Indicator Summary (PRECIS-2) criteria. The criteria specify unobtrusive measurement of participants' protocol adherence and practitioners' intervention fidelity but suggest no special monitoring strategies to assure trial integrity. We present experience with adherence/fidelity monitoring in the Pain Management Collaboratory (PMC) and provide recommendations for their monitoring in pragmatic trials to preserve inferences of treatment comparisons.

METHODS

In November 2021, we surveyed 10 of 11 originally funded PMC pragmatic trials to determine the extent to which adherence and fidelity data were being monitored.

RESULTS

Of the 10 PMC trials, 8 track adherence/fidelity. The electronic health record is the most frequent source for monitoring adherence (7/10) and fidelity (5/10). Most adherence data are used to monitor participant engagement with the trial intervention (4/10) and are reviewed by study teams (8/10) and often with a data and safety monitoring board (DSMB) (5/10). Half of the trials (5/10) reported using fidelity data for feedback/training; such data are not shared with a DSMB (0/10). Only 2 of 10 trials reported having prespecified guidance or rules around adherence/fidelity (eg, stopping rules or thresholds for corrective action, such as retraining).

CONCLUSIONS

As a best practice for pragmatic trials, we recommend early and regular adherence/fidelity monitoring to determine whether intervention delivery is as intended. We propose a 2-stage process with thresholds for intervening and triggers for conducting a formal futility analysis if adherence and fidelity are not maintained. The level of monitoring should be unobtrusive for both participants and those delivering the intervention; resulting data should be reviewed by an independent DSMB.

Adapting to change: experiences and recommendations from the Pain Management Collaboratory on modifying statistical analysis plans

BACKGROUND

Best practices for clinical trials stipulate that statistical analysis plans (SAPs) need to be finalized before initiation of any analysis. However, there is limited guidance about when changes to SAPs are acceptable and how these changes should be incorporated into the research plan with appropriate documentation.

METHODS

We conducted a survey of 12 pragmatic clinical trials (PCTs) in the Pain Management Collaboratory that evaluated nonpharmacological interventions for pain to assess the following SAP information: (1) location of statistical analysis details, (2) types of statistical analyses planned, (3) sponsor requirements, (4) templates used for development, (5) publication plan, (6) changes since trial launch, (7) process of documenting changes, and (8) process of updating the trial registry.

RESULTS

All 12 PCTs provided details of their SAPs for the primary outcomes in the institutional review board-approved trial protocol; 8 included plans for secondary outcomes, and 6 included plans for tertiary/exploratory outcomes. Most PCTs made SAP changes after trial initiation, many as a result of COVID-19-related issues. Eleven of the PCTs were actively recruiting participants. Changes were made to sample size, study design, study arms, and analytical methods, all before the data lock/unblinding. In all cases, justification for the changes was documented in the trial protocol or SAP, signed off by the trial biostatistician and principal investigator, and reviewed/approved by an institutional review board, data and safety monitoring board, or sponsor.

CONCLUSIONS

We recommend that SAP changes can be acceptable up to the time of data lock/unblinding. To maintain full transparency and necessary rigor, clear documentation of such changes should include details, rationale, date(s) such changes were implemented, and evidence of approval by relevant oversight bodies.

Exploring the Experience of Pain and Pain Management for Pregnant and Postpartum Veterans with Chronic Musculoskeletal Pain

BACKGROUND

To examine how veterans experience and treat pain during the perinatal period, we conducted a qualitative study to explore the experiences of pain, pain management, and facilitators and barriers to treatment among perinatal veterans.

METHODS

We identified veterans who received care at any of the 15 Veterans Health Administration (VHA) facilities across the United States and were enrolled in an ongoing cohort study. All participants gave birth to a newborn between March 2016 and June 2021 and met the inclusion criteria for having a prepregnancy pain-related musculoskeletal condition. We completed interviews with 30 veterans between November 2021 and January 2022. We used a framework approach to our qualitative analysis.

RESULTS

Veterans in our sample were, on average, 31 years of age, married (80%), and white (47%). The most common type of pain diagnoses were back pain (93%) and joint disorders (73%). We identified the following major themes: 1) veteran experiences of pain during pregnancy, 2) challenges to pain care during the perinatal period, and 3) veteran recommendations for VHA perinatal pain care. Experiences of pain during pregnancy varied and several barriers to pain care were identified. Veterans suggested several ways the VHA could improve pain care during the perinatal period, including more training for VHA providers on perinatal pain care and greater complementary and integrative health coverage.

CONCLUSIONS

Understanding the unique needs of pregnant veterans with chronic pain is important to provide high-quality care during the perinatal period. Veterans who participated in this study highlighted several areas where the VHA could improve pain management during pregnancy and postpartum.

Musculoskeletal Pain During Pregnancy Among Veterans: Associations With Health and Health Care Utilization

INTRODUCTION

Musculoskeletal (MSK) pain is more likely to be diagnosed in veterans compared with the general population; however, MSK pain during pregnancy has not been studied in veterans. This study examined health and health care use differences between pregnant veterans with and without MSK pain (MSK-).

METHODS

Veterans who delivered a newborn before June 1, 2021, were identified from an existing cohort (n = 1,181). Survey and Veterans Health Administration (VA) electronic health record data were obtained on participants. Veterans meeting inclusion criteria were identified as those with MSK pain (MSK+) and were compared with MSK- participants. We examined differences between primary outcomes of VA health care engagement (including mental health diagnoses, health care visits, receipt of prescription opioids, and complementary and integrative health use) and secondary outcomes (including postpartum variables) between MSK pain groups. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were calculated.

RESULTS

There were 172 veterans (14.6%) who met MSK pain eligibility criteria. In adjusted models, MSK+ veterans were more likely to be diagnosed with major depressive disorder (aOR, 1.76; 95% CI, 1.22-2.53) and post-traumatic stress disorder (aOR, 1.79; 95% CI, 1.21-2.64) during pregnancy compared with MSK- veterans. The use of VA mental health care (aOR, 1.52; 95% CI, 1.09-2.12) and the odds of receiving an opioid prescription during pregnancy (aOR, 2.76; 95% CI, 1.53-5.00) was higher in MSK+ veterans compared with MSK- veterans. Only a small proportion (3.6%) of our entire cohort used complementary and integrative health approaches during pregnancy. MSK+ veterans were more likely to deliver by cesarean section compared with MSK- veterans (36% vs. 26%).

CONCLUSIONS

MSK+ veterans were more likely to be diagnosed with mental health conditions and to use VA mental health care during pregnancy compared with MSK- veterans. Because veterans receive their obstetrical care in the community, understanding the unique needs of pregnant MSK+ veterans in comparison with MSK- veterans is important to provide comprehensive care during the perinatal period.

Protocol for a pragmatic trial testing a self-directed lifestyle program targeting weight loss among patients with obstructive sleep apnea (POWER Trial)

BACKGROUND

Obesity comprises the single greatest reversible risk factor for obstructive sleep apnea (OSA). Despite the potential of lifestyle-based weight loss services to improve OSA severity and symptoms, these programs have limited reach. POWER is a pragmatic trial of a remote self-directed weight loss care among patients with OSA.

METHODS

POWER randomizes 696 patients with obesity (BMI 30-45 kg/m2) and recent diagnosis or re-confirmation of OSA 1:1 to either a self-directed weight loss intervention or usual care. POWER tests whether such an intervention improves co-primary outcomes of weight and sleep-related quality of life at 12 months. Secondary outcomes include sleep symptoms, global ratings of change, and cardiovascular risk scores. Finally, consistent with a hybrid type 1 approach, the trial embeds an implementation process evaluation. We will use quantitative and qualitative methods including budget impact analyses and qualitative interviews to assess barriers to implementation.

CONCLUSIONS

The results of POWER will inform population health approaches to the delivery of weight loss care. A remote self-directed program has the potential to be disseminated widely with limited health system resources and likely low-cost.

Intervention Fidelity in Pain Pragmatic Trials for Nonpharmacologic Pain Management: Nuanced Considerations for Determining PRECIS-2 Flexibility in Delivery and Adherence

Nonpharmacological treatments are considered first-line pain management strategies, but they remain clinically underused. For years, pain-focused pragmatic clinical trials (PCTs) have generated evidence for the enhanced use of nonpharmacological interventions in routine clinical settings to help overcome implementation barriers. The Pragmatic Explanatory Continuum Indicator Summary (PRECIS-2) framework describes the degree of pragmatism across 9 key domains. Among these, "flexibility in delivery" and "flexibility in adherence," address a key goal of pragmatic research by tailoring approaches to settings in which people receive routine care. However, to maintain scientific and ethical rigor, PCTs must ensure that flexibility features do not compromise delivery of interventions as designed, such that the results are ethically and scientifically sound. Key principles of achieving this balance include clear definitions of intervention core components, intervention monitoring and documentation that is sufficient but not overly burdensome, provider training that meets the demands of delivering an intervention in real-world settings, and use of an ethical lens to recognize and avoid potential trial futility when necessary and appropriate. PERSPECTIVE: This article presents nuances to be considered when applying the PRECIS-2 framework to describe pragmatic clinical trials. Trials must ensure that patient-centered treatment flexibility does not compromise delivery of interventions as designed, such that measurement and analysis of treatment effects is reliable.

Pre-implementation formative evaluation of cooperative pain education and self-management expanding treatment for real-world access: A pragmatic pain trial

OBJECTIVE

Cognitive behavioral therapy for chronic pain (CBT-CP) is an evidence-based treatment for improving functioning and pain intensity for people with chronic pain with extensive evidence of effectiveness. However, there has been relatively little investigation of the factors associated with successful implementation and uptake of CBT-CP, particularly clinician and system level factors. This formative evaluation examined barriers and facilitators to the successful implementation and uptake of CBT-CP from the perspective of CBT-CP clinicians and referring primary care clinicians.

METHODS

Qualitative interviews guided by the Consolidated Framework for Implementation Research were conducted at nine geographically diverse Veterans Affairs sites as part of a pragmatic clinical trial comparing synchronous, clinician-delivered CBT-CP and remotely delivered, technology-assisted CBT-CP. Analysis was informed by a grounded theory approach.

RESULTS

Twenty-six clinicians (CBT-CP clinicians = 17, primary care clinicians = 9) from nine VA medical centers participated in individual qualitative interviews conducted by telephone from April 2019 to August 2020. Four themes emerged in the qualitative interviews: (1) the complexity and variability of referral pathways across sites, (2) referring clinician's lack of knowledge about CBT-CP, (3) referring clinician's difficulty identifying suitable candidates for CBT-CP, and (4) preference for interventions that can be completed from home.

CONCLUSIONS

This formative evaluation identified clinician and system barriers to widespread implementation of CBT-CP and allowed for refinement of the subsequent implementation of two forms of CBT-CP in an ongoing pragmatic trial. Identification of relative difference in barriers and facilitators in the two forms of CBT-CP may emerge more clearly in a pragmatic trial that evaluates how treatments perform in real-world settings and may provide important information to guide future system-wide implementation efforts.

Behavioral Health, Telemedicine, and Opportunities for Improving Access

PURPOSE OF REVIEW

The purpose of this review is to summarize advances in behavioral treatments for pain and headache disorders, as well as recent innovations in telemedicine for behavioral treatments.

RECENT FINDINGS

Research for behavioral treatments continues to support their use as part of a multidisciplinary approach to comprehensive management for pain and headache conditions. Behavioral treatments incorporate both behavioral change and cognitive interventions and have been shown to improve outcomes beyond that of medical management alone. The onset of the COVID-19 public health emergency necessitated the rapid uptake of nontraditional modalities for behavioral treatments, particularly telemedicine. Telemedicine has long been considered the answer to several barriers to accessing behavioral treatments, and as a result of COVID-19 significant progress has been made evaluating a variety of telemedicine modalities including synchronous, asynchronous, and mobile health applications. Researchers are encouraged to continue investigating how best to leverage these modalities to improve access to behavioral treatments and to continue evaluating the efficacy of telemedicine compared to traditional in-person care. Comprehensive pain and headache management should include behavioral treatments to address a variety of behavior change and cognitive targets. Policy changes and advances in telemedicine for behavioral treatments provide the opportunity to address historical barriers limiting access.

Justice and equity in pragmatic clinical trials: Considerations for pain research within integrated health systems

Introduction

Methods

Results

Conclusions